Special Edition Gold Dome Report - July 27, 2017

Last week, for two days, the members of the House Rural Development Council met in Thomasville and Bainbridge, focusing on healthcare issues. This Council, co-chaired by Representatives Terry England (R-Auburn) and Jay Powell (R-Camilla), delved further into the challenges and opportunities which rural areas in Georgia face and in particular the struggles many of the State’s smaller hospitals encounter.

There were approximately twenty legislators present, along with House Budget Office Staff, to hear more clearly about the healthcare needs of Georgians in the rural regions.

Thomasville

The meeting in Thomasville had presentations from Commissioner Judy Fitzgerald from the Department of Behavioral Health and Developmental Disabilities; Robin Rau, CEO of Miller County Hospital; Kelli Vaughn, RN, director of the Emergency Department of Archbold Hospital and LeDon Toole, VP for Long-Term Care at Archbold Health System; and Carlton Powell, Thomas County Sheriff, and Troy Rich, Chief of the Thomasville Police Department. Some of the themes repeated in their discussions were the issues that there were too few resources for mental health services (including services for children) and that these individuals are coming to the hospital emergency rooms and there are not enough healthcare providers.

Lawmakers were provided an overview of Thomasville and how it has been progressive from its earliest of roots by Shelly Zorn who is the City’s Economic Developer. She accented that the City had spent $83 million on its downtown over the last 20 years in an effort to draw additional tourists – especially with the 71 hunting plantations in the region. Thomasville is also working on an amphitheater, biking and hiking trails and a conference center/hotel. Downtown Thomasville is a hub for a seven-county region. The population of Thomasville is approximately 44,000 and it is home to a number of large industries including Flowers Bakery, TECT, Cleaver Brothers, Hurst Boiler and others. It also has a number of smaller businesses such as Blackberry Patch, Sweet Grass and others.

Commissioner Fitzgerald talked to lawmakers about the closure of South West Hospital, the current work by her Department, and challenges and opportunities.

In FY 2009, the average daily census at the hospital was 56 adult mental health patients and an additional 126 patients with developmental disabilities. The State executed the settlement agreement with the Department of Justice, under Governor Perdue’s administration, in 2010 which required closure of the hospital on December 31, 2013. It was required that the State partner with individuals with developmental disabilities and their families to build out a system (actually a transformation) to allow those individuals to be placed in the community, reflecting their individual needs and preferences with services closer to their homes.

DBHDD created its Offices of Transition and Wellness in 2015. Within those, the Department has implemented intensive supports and support coordinators for each individual with ongoing monitoring. This has improved and provided enhanced provider capability. In the Department of Justice’s extension agreement, the Department agreed to transition individuals at a “reasonable pace” to the community – now there is an active list of 60 folks being transitioned. Additionally, the Department has initiated behavioral health crisis centers; added additional services; and created mobile crisis response teams. DBHDD will meet its targets and is focused on safety and wellbeing of individuals. The State’s Community Service Boards (“CSBs”) are important in this work and provide a safety net. DBHDD is providing a “continuum of care” and Commissioner Fitzgerald commented on the work by the Governor and General Assembly in making this continuum possible with DBHDD – they are using evidence-based practices; new resources (such as behavioral health crisis centers in Albany, Thomasville and Valdosta); and have received $18 million in new funds in Region 4 to expand infrastructure and community based services.

Commissioner Fitzgerald explained that the behavioral health crisis centers are 24/7 places of care with a front door for emergencies. Additionally, they have stabilization beds and are able to provide assessment, counseling and referrals to help with de-escalation of crises. She gave a quick overview of the local CSBs:

Georgia Pines CSB

Has emergency receiving

Has 24 beds and six temporary observation beds

Has an annual investment of around $5 million

Aspire CSB (Albany)

Has 30 beds with six observation beds

Has emergency receiving

Has an annual investment of around $5 million

Valdosta CSB

Provides behavioral health services

Serves as an emergency receiving facility

Has 24 beds and six observation beds

Has an annual investment of more than $5 million

Commissioner Fitzgerald reminded the Council that in 2013 South West Hospital had 67 beds; now the region has 96 beds with access to more beds through private facilities.

Rep. Jay Powell inquired about individuals being turned away for help and how often that occurred. Commissioner Fitzgerald, along with DBHDD’s Jennifer Dunn, acknowledged that the beds were full and that sometimes individuals would wait in the lobby areas before being directed to a bed – many times those are contract beds. Rep. Darlene Taylor also inquired about the capacity as well as if insurance was billed for services and the numbers of individuals seeking services due to drugs. Approximately, the mix of issues between mental health and drug-related problems is 70/30. Commissioner Fitzgerald indicated that DBHDD is focused on getting the right individuals to the right level of care. She would like more behavioral health crisis centers and the Department has been assessing those needs. Commissioner Fitzgerald acknowledged the need for addictive disease services and that those were nationally under-resourced – so Georgia is not unique in not having enough. It is more challenging to have services in the rural areas. Services which DBHDD does provide include: supported housing; ACT; crisis centers; case management; community support teams; crisis respite apartments; transition care from homelessness; and supported employment. She noted that the response times for mobile crisis was to be one hour or less in the Settlement; DBHDD is at 59 minutes for an average response time. There are private providers providing these services and they must report numbers on their response times.

As of April 2017, there were a total of 1,270 mobile crisis needs (adult mental health were 932 and children and adolescents were 338 of this total number). In Georgia, there are 126 counties using mobile crisis services (assessment times on average are 76 minutes and diversion occurs 93.45 percent of the time).

Rep. Patty Bentley (D-Butler) inquired about services in her district (which includes Taylor, Macon, and Dooly Counties) – Commissioner Fitzgerald outlined that behavioral health crisis centers are new levels of service and not in those counties but there are mobile crisis services and crisis stabilization units (but not all of those have emergency receiving). She did tell Rep. Bentley that GCAL, the State’s crisis and access line, could be reached where it had licensed clinicians answering calls and making decisions on whether to deploy mobile crisis services.

There were also questions about the Rome/Floyd area because of its State hospital closure. The concerns were around the numbers in jail – Commissioner Fitzgerald indicated that she and her Department met twice annually with the sheriffs about the problem with jails receiving many of those needing behavioral health services. Commissioner Fitzgerald did note that one of their primary problems was the workforce shortage – that too is a national problem.

Rep. Ed Rynders (R-Albany) inquired about housing and in particular around requirements on numbers per unit and whether there were square footage requirements – Commissioner Fitzgerald indicated that some of the requirements were dictated by the DOJ settlement but also in the waiver which contained staffing plans.

Rep. Sam Watson (R-Moultrie) inquired about responses from crisis teams to de-escalate situations; many times the team arrives and talks with the individual and family but the situation only reoccurs. Commissioner Fitzgerald mentioned its contract with Beacon Health Options which has new ideas on data collection; it began its work with the State five years ago. She mentioned that at the time she was with a CSB and had concerns about the “reams” of data being submitted to the ASO. However, Beacon is able to show key performance indicators to meet with basic standards; identify what technical support is needed; help drive decisions; have active utilization management; and provide an overall understanding of the system. Commissioner Fitzgerald acknowledged that catching mental health problems early was critical when asked questions – there are few services provided in public schools at the early ages. However, she noted that sometimes that is due to the payer source and what can be provided. DBHDD is serving uninsured youth and the CSBs are providing, through the GAP Program, services to children regardless of insurance. Commissioner Fitzgerald told the Council that interagency meetings routinely take place and that DBHDD is part of planning teams.

There were 1,307 who died of overdoses in 2015 and 68 percent of those were due to opioids. This number is a ten-fold increase between 1999 and 2014. 55 Georgia counties are above the national average in numbers of overdoses. Commissioner Fitzgerald told the Council members that all states received funds for their drug problems; Georgia received $11.8 million for two years (that amount was based on the State’s population), but those federal funds have requirements as to how they may be spent (e.g. access to treatment, prevention, recovery activities, etc.). Additionally, 80 percent of the $11.8 million must be expended on opioid use disorder and recovery. Commissioner Fitzgerald assured the Council members that her Department is working with the Georgia Department of Public Health in looking at prescribers who are writing prescriptions for opioids. DBHDD is responding to the opioid crisis by increasing access to medication assisted treatment for Medicaid enrollees (detox services, residential beds, training on best practices and medication assisted treatment pharmacy benefit); a media campaign; increasing awareness of misuse; reducing stigma; promoting the Good Samaritan Law; promoting prevention activities; using peers to help with the Peer Support Warm Line etc.; and highlighting Naloxone education and training (including distribution of kits to first responders).

Rep. Sharon Cooper (R-Marietta) asked about the new federal department involved with healthcare and its willingness to work on issues. Commissioner Fitzgerald provided an update with its recent discussions with the DOJ which was in July and only involved one lawyer rather than six. Rep. Cooper also stressed she was concerned about the lack of healthcare workforce, including residents in psychiatry and also mid-levels. Fitzgerald indicated the problems are complex with hard work demanded and lack of pay. Telehealth is part of the future; Commissioner Fitzgerald is willing to work with the State’s technical schools in an effort to help utilize those individuals with basic degrees in psychology or social work in screenings (much like nursing assistants).

There were also follow up questions on the death rates of individuals with developmental disabilities who have been moved from the State’s hospitals; Commissioner Fitzgerald indicated that was why the Department is moving more deliberately and with the right supports for those individuals.

Rep. Powell also inquired about access to transportation – getting to follow up appointments and to medications. The “ACT” teams are part of that process in making house calls in rural areas so that individuals with the highest levels of need have their needs met.

Robin Rau, Miller County Hospital

Ms. Rau gave a very lengthy presentation to the Council. Miller County Hospital, which was a critical access hospital (CAH are permitted to bill Medicare and Medicaid on a cost-basis for outpatient services), provides services in Baker, Calhoun and Miller Counties – she provided some demographics:

County

Percentage of individuals below poverty

Percentage of children 0-17 below poverty

Percentage of households without a vehicle

Percentage of households with one vehicle

Percentage of population with a college education

Baker

28.4

41.9

13.2

44.9

8.6

Calhoun

40.5

41.6

15.5

37.2

9.9

Miller

25.2

37.4

7.4

35.6

12.8

Miller has four family practice physicians employed along with a family practice and obstetrics partial support and one podiatrist. They also highly utilize their mid-level providers by staffing their emergency room with these: three emergency medicine mid-levels; two family practice nurse practitioners; and one family practice physician’s assistant. They also have supportive staff: two pulmonologists and two nephrologists.

Ms. Rau explained that in 2007, the hospital was $1.1 million in the red and that worsened the following year. However, in FY 2009 she was hired and they ended the year only $750,000 in the red (refocusing the long-term care services and refinancing the hospital’s $3.5 million debt). Miller County explored the numbers of long term care beds and found that there was one bed for every eight people over the age of 65 within 25 miles of the facility; however, in Metro Atlanta, there is one long-term care bed for every 14 patients over the age of 65. Thus, they tried to locate other cost savings in addition to reducing their debt. They redirected and refocused emergency room patients to help decrease the facility’s uncompensated care. They obtained a retail pharmacy license, although they had a hospital pharmacy, so that patients could maintain medication compliance – they found that nursing home patients on average had 13 prescriptions each in FY 2009. They also worked through various other improvements over the last few years:

Opening a rural health clinic so as to redirect individuals from the emergency room and implementing a sliding scale fee of 200 percent of the federal poverty level

Offering sick visits to local businesses and their employees (but capturing the costs of any requisite “tests” those individuals needed (such as strep test, EKG, etc.)

Ms. Rau mentioned the behavioral health challenges, including the 25 “1013” exams which have taken place between January and June 2017. Of those, 11 were children. She also mentioned the seven year old who committed suicide.

The average time in the emergency room is 10 hours. However, they had one elderly individual which required 17 facilities to be contacted in an effort to find a placement. Now, they use a screening tool, using this with 1,328 individuals. Of those, 48 needed referrals.

In the hospital’s coordination care program, they have enrolled 29 patients in chronic care management. They also use transitional care management (for post-hospitalization care and follow up) and have 383 patients who have been followed. They have seen 587 for annual wellness visits.

The hospital employs 500 and has an annual payroll of $60 million. They have not seen any rate increases since 2008; their revenues are volume driven.

She accented a number of challenges – including workforce. They do offer scholarships for nurses; pay competitive wages and benefits (with an average salary of $45,000); have seen a reduction in the health insurance rates with a $500 deductible; provide free healthcare for employees and their immediate families; offer stipends to nursing school students in Cuthbert; and provide training partnerships with UGA, Bainbridge, Thomasville, Wallace and etc.

Salary expenses experienced in 2012 were $9.6 million and benefits were $2.4 million (or 25 percent) and in 2017 the salary expense was $19.6 million and benefit expense was $4.0 million (or 20 percent). Uncompensated care in 2012 was $3.4 million (9.6 percent of revenue) and in 2016 was $2.5 million (or 4.5 percent of revenue).

Ms. Rau was asked questions about the rural health clinic’s operations. It is operated between 7:00 a.m. and 7:00 p.m. She found that operating longer hours cut into the return due to staffing costs. They are considering opening the clinic now on Saturdays. Rep. Don Parsons (R-Marietta) inquired about scope of practice and utilizing individuals at the top of their license; Ms. Rau indicated that they are using individuals at the limits of their licensure – more so than at other facilities. Rep. Jason Shaw (R-Lake City) brought up permitting APRNs and physicians’ assistants the ability to prescribe Schedule II drugs (that legislation had died during 2017). Ms. Rau also noted that they were lacking EMS services (Baker and Calhoun Counties do not have EMS services). The population of the three counties is between 12,000 and 13,000. Rep. Sharon Cooper (R-Marietta) inquired about screening patients in the emergency room; EMTALA laws require patients to be seen; Ms. Rau stated that this law was a negative impact on Miller County. Emergency room visits are around 15 per day; that number has stayed relatively constant but now the cases seen are more appropriate. Rep. Cooper expressed concern about the mid-levels staffing the emergency room. However, Ms. Rau indicated that there was a physician on call. The Medical College of Georgia also is exploring a program with Miller County so as to train physicians with hands-on care. Miller County has also participated in the Rural Hospital Stabilization Committee and its work, identifying strengths and weaknesses.

Archbold Health System

Kelly Vaughn, RN spoke to the need for behavioral health services. She and her staff find in the Emergency Department a need for more behavioral health staffing. The average length of stay in the emergency room for an individual with behavioral health needs is 11 hours. There is physical space needed and they have patients with chronic care needs as well as psychiatric care needs. She stressed the need for additional services for individuals with autism (the Marcus Center is five hours away) and the need for more regionally located services. She also expressed greater telemedicine help but part of the issue is lack of local access to broadband.

Archbold’s chief nursing officer outlined some facts about the facilities under the Archbold umbrella. They have a total of 540 beds in four hospitals (two of the hospitals are critical access hospitals). They employ roughly 2,500 employees and 900 of those are nurses. The healthcare workforce is a challenge, especially as there are too few nurses in the State. They turn away students due to lack of nursing faculty. The State needs to look at ways in which to keep faculty and improve the salary structure. Registered nurses are also not distributed well within the State. Nurses leave routinely – mostly because they have no idea the commitment they are taking on and the workload. She indicated that there was a need for “shadowing” programs. Rep. Cooper echoed these remarks, indicating that many nurses cannot work on med-surg floors when they complete their education. It was also mentioned that there had been a shift away from using LPNs and instead using higher-degreed individuals. Archbold has a 11.9 percent nursing vacancy; the State’s vacancy rate ranges between six and twenty percent. She noted that turnover costs are $64,000 per position. Recruiting nurses is difficult – especially when taking into account lack of jobs for spouses, education issues in schools, etc. Archbold does utilize scholarships and pays for tuition (requiring a two-three year commitment for such tuition payments); they also offer sign-in bonuses up to $10,000; paying finder’s fees of up to $3,000; repaying of relocation costs; and providing clinical space for local nursing programs.

Law Enforcement

Since the hospital closure at South West, Sheriff Powell indicated that more individuals were placed with the sheriffs across the State. However, sheriffs did not get to provide actual input on these costs. In 2013, there were 998 trips to facilities with patients (those trips were to Columbus, Macon, Savannah and Atlanta). These trips were costs to the counties and the State. In one year, the costs to take these individuals is $450,000 for Thomas County. In 2017, there have been 400 trips made thus far. Many things are causing these issues including more drugs which individuals are using and more federal requirements for jail/prison beds. Rep. Powell asked if the jail or back of the patrol car was the last place that these individuals need to be; Sheriff Powell acknowledged that was accurate. He stated that no one in Atlanta is listening to the Sheriffs’ Association lobbyist Terry Norris. Sheriff Powell told the Council that he and his deputies needed a place closer than 150 miles to take patients.

Chief Rich stressed the need for all police officers to get crisis intervention training (“CIT”) from NAMI. He explained that the training was very beneficial. They have 170 calls annually from individuals who are in crisis; CIT, a 40-hour course, is beneficial. He told the Council that all law enforcement, and interested community members, should receive CIT. He also said it was challenging for his officers to wait one hour for the mobile crisis team to respond; the officers and individuals need help immediately.

Bainbridge

Day two of the House Rural Development Council meeting took place at Bainbridge State College. There were again several presentations including the Federally Qualified Health Centers (Community Health Centers in Georgia – Georgia Association for Primary Health Care Inc.); Department of Community Health; Bainbridge Memorial Hospital; HomeTown Health; and Georgia Board for Physician Workforce.

Federally Qualified Health Centers

Becky Ryles along with Duane Kavka, RB Tucker, and Ann Addison presented on behalf of the Georgia Association of Primary Health Care. These federally qualified health centers are providing primary care in several locations across the State. There are 203 clinic sites in 111 counties with more on the horizon. In 2016, there were more than 500,000 patients served – the bulk of those (42 percent) are uninsured and 27 percent have Medicaid, 11 percent have Medicare and 20 percent have private insurance. They also receive some federal grants.

South Central Primary Care Center was incorporated in 1992 and has doubled in size since 2010 – it served over 4500 patients in 2010 and more than 9500 patients in 2016. It has eight clinic sites (four family medicine, three pediatric and one women’s health).

Primary care health centers are providing jobs with competitive salaries and benefits (health insurance, retirement and paid vacation/sick and holiday time)– the payroll is more than $5.4 million. The Ocilla location partners with its local hospitals (Dorminy Medical and Irwin County) as well as the CSB. They are also providing telemedicine in schools for teachers and students in Atkinson, Berrien and Irwin Counties. They also offer health fairs and health education in the communities – such as blood sugar level and blood pressure checks as well as diabetes education etc. They also provide a setting for clinical rotations – medical assistants and LPNs for Wiregrass Tech; observation for RN students at South Georgia College; clinical training for NPs for students from Georgia Southern, Albany State, South University, and Walden University; and three physician preceptors for residents.

They highlighted the Legislature’s approval of the preceptor tax credit for helping train physicians in rural areas; the sales tax exemption allowing them to see more uninsured; and the State financial support for startup sites (recently started one in Nashville and plan one in Lenox). They suggested the following:

Primary Care of South Georgia started in Blakely in 2006. It originally began with 10 employees and saw 300 patients. Now, it has 88 employees with 4,000 patient visits monthly. In 2007, it opened a site in Thomasville; in 2015 it opened a midwifery center in Thomasville; in 2015 it opened a location in Bainbridge; and it opened in 2017 a location in Quitman. It used State “planning dollars” to open these sites. It also has plans to open school-based health clinics in Thomas County in 2017. In 2016, they had 1,299 behavioral health visits. They also had 210 deliveries and 155 C-sections in 2016.

Through a $1 million grant, it has hired a pediatrician and constructed a 4,000 square foot expansion and added LCSW for integration of primary care and behavioral health.

Primary Care of South Georgia identified several unique projects:

A partnership with Archbold with the health center so that emergency room utilization can be addressed when inappropriate

Partnered with the Cancer Coalition for colonoscopies for uninsured

Partnered with Memorial Hospital and Manor to open a FQHC to decrease emergency room visits of indigent patients and created an emergency room diversion model

They thanked the General Assembly for the preceptor’s tax credit as well as the sales tax exemption which has allowed it to use those dollars saved to expand mental health. They identified needs:

Expansion of broadband services beyond the city limits in rural Georgia.

Mr. Dev Watson, the Chief Information Officer for the Association, spoke about health information technology (“HIT”). The Georgia Association of Primary Healthcare members were early leaders in electronic medical records’ adoption and utilized initial seed funding provided by the General Assembly in 2006. All of the Association’s members have certified electronic medical records since 2012 and in 2017 all have implemented a certified health information technology. He went through a number of electronic medical platforms being used (e.g., Athena Health, NextGen, Epic, etc.) and outlined the “hosting” model used (internal or self, vendor hosted, and health center controlled). 86 percent of the providers use electronic medical platform from two vendors. Their current projects are involving interoperability/data sharing (through Georgia HIN, Department of Community Health and Care Partners); expansion of telehealth services; connectivity improvements; comprehensive health tracking; and data analytics. Mr. Watson enumerated a number of HIT challenges: affordable high speed broadband; health data analytics staff; information technology staff (not just someone who likes computers); and policy and payment guidelines (for telehealth and home monitoring, including smart phones). He made these recommendations:

Residency program for family practitioners in South Georgia

Loan repayments

High speed broadband

Encouragement of behavioral health and primary health integration

Preceptors’ tax credit to help increase the workforce

Streamlining of the credentialing process for behavioral health providers

Continuing the sales tax exemption enjoyed by FQHCs

Permitting billing for licensed professional counselors for behavioral health services in a safety net setting

Rep. Ed Rynders (R-Albany) inquired about the numbers of counties which were “medically underserved.” There are 38 counties in Georgia which need quality healthcare services. Cost is a big driver in delivering services. The FQHCs require $250,000 in seed money in order to begin; there are third-party billing sources but those are a delicate balance as 42 percent of the patients seen by the centers are uninsured.

Rep. England asked about telehealth billing and in particular Medicaid. His concerns were around whether the challenges or hurdles for providers were with the State or federal requirements – Mr. Watson stated that they were both. The also talked some about the “warm” handoff by providers in primary care to help serve those with behavioral health needs. The major challenge is the one visit billed per day; if that could be changed, it would help. Credentialing of providers is another issue – it takes long periods of time to get providers credentialed. Some stated that a squash crop could be planted and harvested in the time it takes to get providers credentialed. Lawmakers also inquired about health fairs – those are hosted by the FQHCs in the communities. All of the FQHCs have federal grant funds; they apply for those funds to become operational. The grants are competitive with each being scored. Some of the FQHCs get funds for their IT and telemedicine efforts and each handles those issues differently.

There was testimony that the centers would like more residency programs. They would also like to see incentives to get more medical students and for those students to do rotations in the FQHCs. There have been discussions with Mercer as well as the Medical College of Georgia (there was no mention of Morehouse).

Rep. Powell inquired about the “open slots” that FQHCs keep to help serve those individuals who present at emergency rooms for care when their care needs are really not emergent. This type of emergency room diversion does take place in the FQHCs and their processes are handled differently in each. They did state that having a FQHC on the hospital’s campus makes it easier to accomplish.

Department of Community Health

Commissioner Frank Berry was slated to make a presentation but was conflicted; Andrew Johnson provided an update to the Committee in Commissioner Berry’s place.

Mr. Johnson acknowledged the opioid epidemic and that the Department has been concerned about its impact on citizens. Johnson outlined that the Department is watching the federal debates on the repeal of the Affordable Care Act – in particular funding for Medicaid and addressing Medicaid eligibility. He indicated that many individuals eligible for Medicaid are not presently enrolled. Growth of the program, though, does continue year over year. Some individuals become frustrated with the application process.

DCH’s budget consumes $14.5 billion in funds (with State and federal moneys). DCH has 1,000 employees and oversees a number of different programs including Medicaid, PeachCare for Kids, health planning functions, and the State Health Benefit Plan. There are also “enterprise” supports which DCH also oversees – such as vendor management and strategy issues.

There are approximately 650,000 individuals covered by the State Health Benefit Plan. There are 800 payroll locations for State Health Benefit Plan. It does offer a telemedicine benefit as well as a “virtual” visit benefit. DCH has found that some of its members are challenged with broadband issues as well as not having “smart phones” in order to participate with the telemedicine and virtual visit benefits.

State Health Benefit Plan has three options – Blue Cross Blue Shield, Kaiser Permanente (metro Atlanta area only), and United Healthcare. United also has the Medicare Advantage plan options.

Mr. Johnson also discussed the Office of Rural Health within the Department. It is located in Cordele and administers a number of grants, including those for the Federally Qualified Health Centers. It also provides technical assistance to providers and provides support to the Rural Hospital Stabilization Committee. That Committee was awarded $3 million in FY 2018 for 12 hospitals (each receiving $250,000) for approved projects (such as Miller County Hospital). Johnson also talked briefly about the Office of Rural Health’s farm worker program which helps provide health screenings to individuals from 5:00 p.m. until 10:00 p.m. (basic primary care).

There are approximately two million individuals enrolled in Georgia’s Medicaid program. Inside that, there are roughly 500,000 individuals covered by the Aged, Blind and Disabled program (which is approximately 50 percent of the Medicaid budget) and 1.4 million individuals covered under the Low-Income Medicaid (these individuals receive care through the CMOs). Finally, 128,000 are covered under PeachCare. He spoke generally about Medicaid eligibility including that it would cover pregnant women, low-income, children under the age of 19, legally blind, disabled and individuals who need nursing home care.

Under the Affordable Care Act, states were required to have presumptive eligibility in Medicaid. There are qualified hospitals in Georgia who participate and provide the expedited enrollment. DCH administers the training – they look at an individual’s income and household size. There are 47 participating hospitals in this effort and there are 22 trainings scheduled in 2017.

Mr. Johnson also mentioned Georgia’s Right from the State Medicaid program. It is located in 159 counties in the local DFCS’s offices.Medicaid eligibility for long-term care benefits, Katie Beckett, Health Babies, etc. apply online through www.gateway.ga.gov.

DCH is aware of the transportation challenges in the rural areas.

Children’s Mental Health is another area of focus for DCH. Governor Deal has recently appointed a Commission to look at Children’s Mental Health. They will be reviewing fee-for-service Medicaid as well as managed care processes and services. This effort is in partnership with the Department of Behavioral Health and Developmental Disabilities, Division of Family and Children’s Services and Department of Public Health. Johnson acknowledged that there is a renewed focus on quality outcomes. The State’s plan services are done in connection with the Department of Behavioral Health and Developmental Disabilities. They meet monthly on priorities. Approximately 50 percent of Georgia’s children are covered by Medicaid. Johnson noted that Georgia had engaged in managed care due to the “runaway” costs in the Medicaid program and those CMOs have helped improve the program financially and now are focusing on quality of care.

Johnson noted that DCH’s challenges are workforce, access and the medical provider application. DCH is also reviewing the Medicaid State Plan in an effort to look closely at support for rural areas. Same day billing for two services was acknowledged as a problem. Provider credentialing has been another issue; DCH has moved forward with a centralized credentialing application process with the CMOs.

Memorial has 80 licensed beds but generally it is staffed for 40-45 beds. The nursing home has 107 beds. The facilities employ 450 full time equivalents and have an annual revenue of $45 million.

Memorial had a loss of $4.83 million in FY 2015; and a loss of $6.35 million in FY 2016. However, in FY 2017, it turned a corner with a net income of $230,000 and shows a first quarter net income for FY 2018 of $244,000. Memorial went back to the basics on revenue, resizing cost structures and improving productivity to lower its operating costs. They have also worked to have better city and county supports. Its indigent care reimbursement from the city and county has also improved and they have developed new service lines and business opportunities – all of these are similar to what Miller County Hospital shared with the Committee in the Thomasville meeting.

Gregg Magers is a “rescue expert” and is serving as the interim CEO. He is with a Texas-based entity which does turnarounds for hospitals. He noted that there are lots of financial stresses on small hospitals especially in states that did not expand Medicaid. The middle-sized hospitals in rural areas are his clients. They have worked in Oklahoma, Texas, Louisiana, and Arizona. Liquidity is the largest concern – especially in meeting payroll. Volume (for services) has dropped in these facilities. Retention and recruitment of physicians and others on medical staff are problematic. Thus, the low volume of patients is not covering the operating costs. His first priority was to look at operating issues, resizing the volume. They cannot just cut costs and solve all the financial problems. The two successive years with financial losses were disastrous. Hospitals need subsidies (UPL payments and revenue enhancements). The city and county support for refinancing the facilities’ debt was important along with the indigent care reimbursement. The executive team and employees want to perform at a high level so that they provide quality patient care and provide satisfactory results. Magers did note that along with rural areas come pockets of poverty. The Georgia Medical Care Foundation has been looking more at this issue – providing well care is less costly than providing sick care. Other challenges exist – employee satisfaction (salary issues); workforce development and the shortage (including technology, nursing, mental health and therapy); technology tools and analytics for population health initiatives; new service line support; and physician recruitment and retention.

Memorial has worked with Stratus Healthcare and also has collaborated with Emory and Medical College of Georgia (as a new training site). They have opened some new services: telenephrology; outpatient lab services; and are looking at others. Memorial has been aggressive in physician recruitment.

Memorial indicated that the State could help financially. It could help with grant programs for the population health initiatives as well as value-based contracting. The State could also provide enhanced reimbursement/support on the integration of primary care and mental health. The State could also review physician recruitment. Grants also would be helpful (especially on hospital readmission prevention efforts, etc.). The State could also provide more incentives for physician recruitment as well as develop a rural residency program and include increased scholarship incentives for technology schools training the workforce. There were several “general” support ideas outlined – such as more raining for hospital authority board members, creation of a Rural Center of Excellence for Healthcare, and expansion of the support of internships and training in the rural areas.

It was noted that the average per capita income in Decatur County was $19,000. However, even the lowest paying jobs at the hospitals were in excess of the average of the per capita amount of income. Thus, legislators need to help protect the hospital’s impact on the economic health of the community as it also helps support the local tax base.

There is also a need for clinical support from the State. Decreased bureaucracy and administrative burdens (from Medicaid especially including the CMOs) would be helpful. They also need encouragement of standardization of quality metrics from all payers. They also suggested allowing an update to attestation of rural primary care physicians and the development of swing bed, post-acute and home health initiatives for prospective payment systems for rural hospitals.

Rural health is important – it needs to be addressed as Georgia has a number of poor healthcare outcomes – including the worst in the country with maternal mortality. Additionally, Georgia’s mental health system is challenged. The rural health jobs are important to the rural counties’ economies and having access to healthcare is vital to produce new or expanding businesses in the State.

The tax imposed for Memorial was a “game changer” as it is helping address the costs of indigent care. Two mills have been placed as the cap; last year, the local county had 1.58 mills assessed which generated $1.3 million. Rep. Tom McCall (R-Elberton) asked if the indigent care patients were coming from outside of the State; he was told no.

Sen. Burke did accent that the hospital needed capital improvements – the hospital’s infrastructure is aging. The State needs to address the mental health challenges and address generational poverty and the lack of opportunity (education, job training, housing and transportation).

HomeTown Health

Jimmy Lewis, CEO of HomeTown Health, spoke about the challenges and opportunities for rural hospitals. Over the last three plus years, Georgia has seen eight hospitals either close or downsize significantly. There are presently 15 hospitals in the State which are considered financially fragile; six of those are in the rural area and could easily close due to poor cash. Lewis told the Council that these facilities are the economic engines in their areas; closures often leave the areas in near “third-world” healthcare. Georgia’s rural profile no longer supports rural hospitals – currently, a rural area is defined as having populations of 35,000 or fewer; many states define rural as populations of counties with 50,000 or fewer. He outlined the recent hospital closures and/or sales: Glenwood, Arlington, Stewart Webster, Telfair, Hart, Hutcheson, Ellijay, Jenkins, Charlton, and Oconee Regional. He stressed that hospitals need to diversify their business lines but cautioned that healthcare really is broken. He further outlined that under the most recent plans from “Trump Care” there would be 600,000-700,000 more Georgians without health insurance. Under the Trump plan, there would be $880 billion cuts to support tax reform efforts as well as block grant financing with per capita financing and would include changes to DSH and UPL payments.

The Governor has instituted a Rural Hospital Initiative which has included sustainability and relationships with funding for hospitals – under phase one there were four facilities which received $750,000; in phase two, three hospitals were awarded $1 million each; and in phase three there are 12 hospitals receiving $250,000. Paramedicine has been found to help manage the high utilizers; school-based telemedicine is also helpful. However, hospitals' emergency rooms really have only five percent of their cases which are true emergencies – others are generally cases which could be handled through urgent care. He also noted that Georgia does have an ambulance system which is connected via the internet. Collaborations with the FQHCs are helpful.

He noted that “local policy” was critical. Local subsidies with a referendum and SPLOST are useful. He suggested that there are 49 needy hospitals. Redefining the term, ‘rural’ would be helpful and would add eight hospitals to this needy list (Washington Regional, Oconee Regional, Coffee, Colquitt Regional, Murray, Camden, Archbold, and Waycross). It takes at least 40,000 residents to support a rural hospital. UPL and DSH payments are shrinking and facilities have leaned on those. For each FTE, it requires net revenue of $103,000. He suggested front-end collections. Denials at one percent of claims processed monthly as the benchmark and 70 percent overturn rates were common in rural hospitals.

Emergency room mandates were brought up. Blue Cross will no longer pay for non-emergent care. As noted, 95 percent of the cases are non-emergent. CMOs also only pay at $50.00 or less for non-emergent care. EMTALA (federal law for patients to be seen if they show up in emergency rooms) has caused financial issues. He indicated that the math of 95 percent of 2,500 ER visits (which are non-emergent) at an average cost of $670 costs $1.6 million monthly.

He mentioned the financial burden that occurs to counties when they are subsidizing hospital bonds.

There was also mention of the payer mix as well as the numerous payer platforms that hospitals must use based on the various insurance plans. Smaller facilities do not have the staffing to address those payment platforms.

Since 1999, Georgia’s payments in the Medicaid program have been around 85.6 percent which is less than cost for the provision of healthcare services. Thus, it has caused a shortage of $1 billion in the system. Self-pay uninsured individuals are 17-20 percent of the hospital patient base. EMTALA issues also are a huge issue for hospitals.

He urged lawmakers to pay Medicaid at cost; pay telemedicine at the market rate; expand scope of practice for physician’s assistants, nurse practitioners and other mid levels to help offset the physician shortage.

Lewis mentioned that successful hospitals diversify and have populations in their county of more than 40,000 (or in their service area) and if not they consolidate. Hospitals also must embrace change and they need “c-suite” continuity as 40 percent only have staffing that have been with the facility for five years. He also urged hospitals to have at minimum of $103,000 per FTE (in revenue).

Georgia Board for Physician Workforce

LaSharn Hughes presented information on Georgia’s physician workforce. Georgia’s FY 2018 Budget has funding of change of more than $2.1 million to provide funding for up to 110 new residency slots at new and existing GME (graduate medical education) programs (the base is $11.1 million).

Georgia’s medical school enrollment numbers were shared with the Council – a total enrollment for all schools is 2,797. Georgia residents are 2,060 of that number. There are more than 15 percent of Georgia’s graduating physicians who have debt of $350,000 or more. With service cancelable loans, physicians agree to practice in counties with 35,000 populations or less. There is 66.7 percent retention with loan repayments. Ms. Hughes mentioned that 21.2 percent of Georgia’s physicians, who are ages 50 and older and practicing in rural areas, are retiring in the next five years. Service cancelable loans are good ways to attract not only physicians but also dentists, physician’s assistants and advanced practice registered nurses to rural areas. There are nine counties in Georgia which do not have a physician (Echols, Glascock, Long, Quitman, Schley, Taliaferro, Treutlen, Webster, and Wheeler – thus, they do not have a hospital). Ms. Hughes did accent that the Board does conduct practice opportunity fairs. She proposed that lawmakers increase the number of recipients of the loan repayment programs; create a pipeline to connect rural middle and high school aged youth with medical schools/medical professions; expand the number of slots at current GME programs and develop new GME programs. She also encouraged community involvement (such as churches, schools, banks, etc.) to build an infrastructure around new physicians and work with local industries to make them aware of physicians in their communities.

Questions

There were numerous questions raised. Rep. Rynders inquired about the Medicaid reimbursement rate of 85.6 percent and why hospitals and providers wanted to expand Medicaid if the reimbursement was not covering cost of provided services. The providers shared that some reimbursement was better than none. He argued entitlement with the program. Further, Rep. Rynders suggested that perhaps the State needed to look at where hospitals should be located, based on the 40,000 population requirements. It was explained that Georgia had done some of that work through the Rural Hospital Stabilization Committee – looking at the hub and spoke models. Rep. Rynders also asked about CON and the “profitable” streams of revenue for hospitals and how those could be balanced.

Rep. Dominic LaRiccia (R-Douglas) indicated that he heard the healthcare system was broken – but it depended on who you asked. He believes it is partisan. Further he stated that perhaps, if there were fewer individuals on Medicaid, then there would be more funds for the folks who are in need.

Members also asked questions about the payer platforms and EMTALA requirements.

Rep. Powell asked Andrew Johnson about DCH’s use of waivers and in particular if Georgia had looked at other states’ cost savings and barriers. Georgia has a number of waivers in place now which allow for things to be paid which are not under Georgia’s Medicaid State Plan (these are 1115 waivers such as Planning for Healthy Babies). Rep. Powell asked that DCH look specifically for rural health. Rep. Powell also asked about individuals who may want to work but are not able to work because they will make too much money and not be able to participate in Medicaid (he also recited one incident where an individual turned down a job promotion in order to keep a Medicaid waiver). Mr. Johnson explained that Medicaid had income eligibility requirements. Rep. Powell also inquired about Medicaid benefits termination when an individual is incarcerated; Mr. Johnson noted that Georgia has been reviewing that to determine if was better for “suspension” or “termination.”

Sen. Burke did counter that Health and Human Services Secretary Tom Price (and former member of the Georgia General Assembly and United States Congressman) stated that he would entertain innovative ideas that make sense. However, Sen. Burke told the House members that it will take years for reform and it will require pilot initiatives.

Rep. Patty Bentley (D-Butler) asked if Medicaid expansion was an option or was on hold. Jimmy Lewis stated that he had “no clue.” Rep. Bentley also asked Ms. Hughes if she would look closer at the counties of Dooly, Macon and Taylor – asking for GME programs in those counties.

The next meeting of the Council will be held in Ellijay on August 15 with a meeting the following day (August 16) in Dalton – those meetings will focus on labor and employment and education issues. The next Council meeting where the focus will be on healthcare will be held in Metter which will be on September 6-7, 2017.

Our 2017 Georgia Capitol team consists of Stan Jones, Helen Sloat, Chuck Clay, George Ray, and Logan Fletcher. We will also try our hand at tweeting this year – so follow us! @GDR_Live

The articles published in this newsletter are intended only to provide general information on the subjects covered. The contents should not be construed as legal advice or a legal opinion. Readers should consult with legal counsel to obtain specific legal advice based on particular situations.